Clinical Data for interviewed patients.
\r\n\tHowever, despite the positive outlook and trends in routing protocol design, there are still several open or unresolved challenges that researchers are still grappling with. Providing adequate responses to those challenges is essential for next-generation networks in order to maintain its reputation and sustain its preponderance in cyber and physical security. Some of the challenges include, but are not limited to, the following:
\r\n\t• Robustness and reliability of routing protocol
\r\n\t• Reduced dependencies on heterogeneous networks
\r\n\t• Security of routing protocols
\r\n\t• Dynamic Adhoc routing Protocols
\r\n\t• Routing in 5G Networks
\r\n\t• Routing IoT enabled networks
\r\n\t• Scalable and dependable routing system architectures
\r\n\t• QoS and QoE Models and Routing Architectures
\r\n\t• Context-Aware Services and Models
\r\n\t• Routing Mobile Edge Computing
\r\n\tThe goal of the book is to present the state of the art in routing protocol and report on new approaches, methods, findings, and technologies developed or being developed by the research community and the industry to address the aforementioned challenges.
\r\n\tThe book will focus on introducing fundamental principles and concepts of key enabling technologies for routing protocol applied for next-generation networks, disseminate recent research and development efforts in this fascinating area, investigate related trends and challenges, and present case studies and examples.
\r\n\tThe book also investigates the advances and future in research and development in Routing Protocols in the context of new generation communication networks.
Anorectal malformations (ARM) are a spectrum of congenital caudal end defects affecting the normal development of the anus and rectum that are usually easily detected after birth by physical examination. They are relatively common, occurring in approximately 1 in 5,000 live births, and vary markedly in severity. ARM is frequently associated with other congenital anomalies that may have a much more severe impact on long-term prognosis [1]. ARM are classified into low, intermediate and high subtypes depending on the relationship of the defect to the pelvic floor musculature [2]. A variety of surgical procedures have been developed for their correction, but despite this faecal incontinence is a well-recognized long-term complication that is said to occur in between 10% to 33% or more of patients with ARM [3-6].
Most reviews of outcome after surgical repair of ARM grade continence into broad classifications of “good”, “fair” or “poor”, based on scoring systems developed by Kelly [7], Templeton [5], Kiesewetter [8] or Wingspread [9]. Faecal incontinence has a significant impact on quality of life in both children and adults [10]. These classification systems have been crucially important in providing statistical information about incontinence but provide little help in understanding how and when incontinence occurs, and its impact at an individual level.
The aims of our study were to define the extent, severity and types of faecal incontinence in children after surgical repair of anorectal malformations, as well as its impact on health care usage, medication, dietary intake, and quality of life. We also wished to relate these outcomes to the level of abnormality, whether “high”, “intermediate” or “low”.
Ethical approval for this study was obtained from the Ethics in Human Research Committee of the Royal Children’s Hospital (Approval number EHRC 21118B)
We planned to recruit all patients who had presented for treatment of anorectal malformations to the Royal Children’s Hospital, Melbourne between 1974 and 2001. Subjects were identified through ICD coding of medical records. We included patients coded with the diagnoses of anorectal agenesis, rectal atresia, anal agenesis, anorectal stenosis (1970-80; ICD 751.30-33); colonic atresia and stenosis, imperforate anus, anorectal agenesis, anal agenesis (1981-88; ICD 751.20-23); atresia and stenosis of large intestine, rectum and anal canal (1989-2002; ICD-10-AM, 751.2, q42.1-3, q42.18, q 43.6).
We excluded those who were deceased, or non-English speaking, or permanently resident overseas. Clinical information was obtained from medical records. Patients were sub-divided into either a combined high and intermediate category or a low malformation category based on coding information. We also inspected operative notes and separately confirmed correct classification of the level of malformation using the Wingspread Conference criteria [11]. Most patients had the same classification irrespective of the method used. Discrepancies between the two were resolved after inspection of the notes by a paediatric surgeon (RGT).
Recruitment packs were mailed to the most current address recorded in the hospital records. Each recruitment pack contained a detailed information sheet about the study and an initial consent form to allow further discussion of the project. Upon receipt of the signed consent form, we contacted each subject or parent by phone to provide further detailed information about the project and to schedule a detailed interview to administer a structured questionnaire.
The 70-item questionnaire was administered either in person, by phone or by mail. The questionnaire had been modified from previous studies on outcome after surgical repair of Hirschsprung disease [12-14]. The revised questionnaire incorporated more detailed information related to bowel function, including amount and awareness of soiling as well as constipation. Further questions were included which related to physical and social functioning, current provision of health care and general health status. The questionnaire was further modified to enable it to be completed by patients as well as parents.
The revised questionnaire was piloted on 21 patients with Hirschsprung’s disease. No significant further modifications were required.
Following the interview, respondents were asked to complete a four-week diary detailing bowel habit, faecal soiling, abdominal pain, enuresis and any medical therapy. This was also based on the diary used for the previous study [12]. Soiling was classified into two groups (“light” and “heavy”) using the amount and frequency of episode. “Heavy” soiling was classified as being larger than a streak (able to be scraped from underclothing) and occurring at least once a month. “Light” soiling was classified as being no larger than a streak (unable to be scraped from underclothing) and occurring less than once a month. Functional testing, including anorectal manometry and electromyography, was offered [15].
Data from patients who had Down’s syndrome was analysed separately.
Statistical analysis was performed using SPSS version 12.0 (Statistical Package for the Social Sciences). Where appropriate, we used t-test, One-Way ANOVA, Chi-square or Fisher’s Exact test, Mann-Whitney U Test or Kruskal-Wallis Test. Results were considered significant if p<0.05. Data are reported as mean ± standard deviation. Patients who were still in nappies because they were too young to be toilet trained were excluded from some analyses. Missing data are reflected in n values.
353 patients were identified from ICD coding. We excluded 21 patients for whom we could not obtain permission from the treating surgeon. This was primarily because these surgeons were no longer in practice and had the effect of reducing the number of older patients. A further 34 patients were excluded who were deceased, 2 from overseas, 2 who needed an interpreter and 8 with inadequate contact details. 286 recruitment packs were mailed. Of these, 67 were returned by the post office with “wrong address” and no forwarding details, and no responses were obtained from a further 110 patients. 35 respondents declined or were unable to participate in the study. 74 respondents agreed to participate in the study, of whom 67 were interviewed. Two of the interviewed patients were later excluded because of an incorrect diagnosis. 57 were interviewed over the phone, 7 face to face and 1 via mailed questionnaires. Three patients had Down’s syndrome.
The average age of the 62 interviewed patients without Down’s was 11.4 ± 6.4yr; 41 were male and 21 female. The average age of the patients who were presumed to be alive but not interviewed was 18.2 ± 8.4yr of whom 428 were male and 275 female. Interviewed patients were younger (p<0.001) but gender proportions were similar (p=0.59). Four patients who wore nappies were excluded from some analyses. Two wore nappies only overnight (mean age 5.2 ± 1.6yr) and two were too young to be toilet trained, wearing nappies both day and night (mean age 2.4 ± 0.1yr).
12 patients underwent anorectal manometry and electromyography.
Clinical Data (n=62) (Table 1)
There were 28 patients with high/intermediate and 34 with low anorectal malformations. Both groups were similar in age, occupational prestige and family status. Eight patients who had developed significant faecal incontinence had undergone redo posterior sagittal ano-rectoplasty (PSARP) [16]. Of these, seven had high/intermediate malformations. Patients with high/intermediate malformations were more likely to have co-morbidity.
\n\t\t\t\tHD\n\t\t\t | \n\t\t\t\n\t\t\t\tHigh/Intermediate (n=28)\n\t\t\t | \n\t\t\t\n\t\t\t\tLow (n=34)\n\t\t\t | \n\t\t\t\n\t\t\t\tp\n\t\t\t | \n\t\t\t\n\t\t\t\tTotal\n\t\t\t | \n\t\t
Age (years) | \n\t\t\t11.8 ± 6.2 | \n\t\t\t11.1 ± 6.7 | \n\t\t\t0.65 | \n\t\t\t11.4 ± 6.4 | \n\t\t
Gender | \n\t\t\t21M:7F | \n\t\t\t20M:14F | \n\t\t\t0.18 | \n\t\t\t41M:21F | \n\t\t
Daniel Occupational Prestige Score | \n\t\t\t4.4 ± 1.0 | \n\t\t\t4.3 ± 0.9 | \n\t\t\t0.81 | \n\t\t\t4.4 ± 1.0 | \n\t\t
Single Parent Family n (%) n=62 | \n\t\t\t7 (11.5) | \n\t\t\t7 (11.5) | \n\t\t\t0.68 | \n\t\t\t14 (23) | \n\t\t
Co-morbidities n (%) n=62 | \n\t\t\t21 (34) | \n\t\t\t15 (24) | \n\t\t\t0.01 | \n\t\t\t36 (58) | \n\t\t
Subsequent PSARP | \n\t\t\t7 (87.5) | \n\t\t\t1 (12.5) | \n\t\t\t0.02 | \n\t\t\t8 (100) | \n\t\t
Clinical Data for interviewed patients.
Bowel Habit (n=60) (Table 2)
Patients with a past history of either high/intermediate or low malformations passed a similar number of bowel actions each week (5.5 ± 1.8). Patients with a history of PSARP had more bowel actions each week, although this just failed to reach statistical significance (PSARP 6.6 ± 1.1 vs no PSARP 5.3 ± 1.8, p=0.052). Patients with high/intermediate malformations were more likely to have a looser (liquid or pasty) stool consistency.
\n\t\t\t | \n\t\t\t | \n\t\t\t\tHigh / Intermediate\n\t\t\t | \n\t\t\t\n\t\t\t\tLow\n\t\t\t | \n\t\t\t\n\t\t\t\tp\n\t\t\t | \n\t\t\t\n\t\t\t\tTotal\n\t\t\t | \n\t\t
Bowel actions per week | \n\t\t\t\n\t\t\t | 5.9 ± 1.6 | \n\t\t\t5.2 ± 1.9 | \n\t\t\t0.13 | \n\t\t\t5.5 ± 1.9 | \n\t\t
Stool consistency n (%) | \n\t\t\t\n\t\t\t | \n\t\t\t | \n\t\t\t | \n\t\t\t | \n\t\t |
\n\t\t\t | Liquid | \n\t\t\t3 (10.7) | \n\t\t\t1 (3.1) | \n\t\t\t\n\t\t\t | 4 (6.7) | \n\t\t
\n\t\t\t | Pasty | \n\t\t\t11 (39.3) | \n\t\t\t6 (18.8) | \n\t\t\t\n\t\t\t | 17 (28.3) | \n\t\t
\n\t\t\t | Formed | \n\t\t\t7 (25) | \n\t\t\t21 (65.6) | \n\t\t\t\n\t\t\t | 28 (46.7) | \n\t\t
\n\t\t\t | Variable | \n\t\t\t7 (25) | \n\t\t\t4 (12.5) | \n\t\t\t0.01 | \n\t\t\t11 (18.3) | \n\t\t
Bowel habit data for interviewed patients.
Faecal Continence (n=57) (Table 3)
Impairment in sensation of impending stool was common (38%), as was faecal urgency (74%), difficulty in holding back stool (40%) or controlling flatus (48%) and discriminating stool type (33%).
Patients with high/intermediate malformations were more likely to have difficulty sensing impending stool and holding it back. Younger patients were more likely to experience episodes of faecal urgency (urgency: young 0-11yr 30/36 vs old 12-33yr 12/21, p<0.05). Patients were more likely to have had episodes of faecal soiling during the last year when they also reported problems with sensation, holding back stool, urgency and stool discrimination. (Impaired sensation of impending stool: soiling 17/35 vs no soiling 3/26, p<0.05; inability to hold back stool: soiling 22/38 vs no soiling 0/15, p<0.001; faecal urgency: soiling 34/42 vs no soiling 8/15, p<0.05; or problems with stool discrimination: soiling 14/30 vs no soiling 1/14, p<0.05).
\n\t\t\t | \n\t\t\t | High/Intermediaten (%) | \n\t\t\tLown (%) | \n\t\t\t\n\t\t\t\tp\n\t\t\t | \n\t\t\tTotaln (%) | \n\t\t
Sensation impending stool (n=53) | \n\t\t\tNever/Rarely/Sometimes | \n\t\t\t15 (62.5) | \n\t\t\t5 (17.2) | \n\t\t\t\n\t\t\t | 20 (37.7) | \n\t\t
\n\t\t\t | Often/Always | \n\t\t\t9 (37.5) | \n\t\t\t24 (82.8) | \n\t\t\t0.00 | \n\t\t\t33 (62.3) | \n\t\t
Faecal urgency (n=57) | \n\t\t\tYes | \n\t\t\t17 (65.4) | \n\t\t\t25 (80.6) | \n\t\t\t0.19 | \n\t\t\t42 (73.7) | \n\t\t
Faecal urgency – frequency (n=36) | \n\t\t\tRarely/Sometimes | \n\t\t\t9 (69.2) | \n\t\t\t12 (52.2) | \n\t\t\t\n\t\t\t | 21 (58.3) | \n\t\t
\n\t\t\t | Often/Always | \n\t\t\t4 (30.8) | \n\t\t\t11 (47.8) | \n\t\t\t0.32 | \n\t\t\t15 (41.7) | \n\t\t
Ability to hold back stool (n=55) | \n\t\t\tNever/Rarely/Sometimes | \n\t\t\t14 (53.8) | \n\t\t\t8 (27.6) | \n\t\t\t\n\t\t\t | 22 (40) | \n\t\t
\n\t\t\t | Often/Always | \n\t\t\t12 (46.2) | \n\t\t\t21 (72.4) | \n\t\t\t0.05 | \n\t\t\t33 (60) | \n\t\t
If able to hold back stool – how long? (n=44) | \n\t\t\tSeconds | \n\t\t\t4 (21.0) | \n\t\t\t2 (8) | \n\t\t\t\n\t\t\t | 6 (13.6) | \n\t\t
\n\t\t\t | Couple minutes | \n\t\t\t12 (63.2) | \n\t\t\t16 (64) | \n\t\t\t\n\t\t\t | 28 (63.6) | \n\t\t
\n\t\t\t | Greater than 30 mins | \n\t\t\t3 (15.8) | \n\t\t\t7 (28) | \n\t\t\t0.38 | \n\t\t\t10 (22.7) | \n\t\t
Discriminates stool consistencies (n=45) | \n\t\t\tNever/Sometimes | \n\t\t\t9 (45) | \n\t\t\t6 (24) | \n\t\t\t\n\t\t\t | 15 (33.3) | \n\t\t
\n\t\t\t | Always | \n\t\t\t11 (55) | \n\t\t\t19 (76) | \n\t\t\t0.14 | \n\t\t\t30 (66.7) | \n\t\t
Stool discrimination type (n=34) | \n\t\t\tFormed & liquid | \n\t\t\t0 (-) | \n\t\t\t1 (5.3) | \n\t\t\t\n\t\t\t | 1 (2.9) | \n\t\t
\n\t\t\t | Formed & gaseous | \n\t\t\t12 (80) | \n\t\t\t11 (57.9) | \n\t\t\t\n\t\t\t | 23 (67.7) | \n\t\t
\n\t\t\t | Formed & liquid & gaseous | \n\t\t\t3 (20) | \n\t\t\t7 (36.8) | \n\t\t\t0.36 | \n\t\t\t10 (29.4) | \n\t\t
Uncontrolled flatus (n=29) | \n\t\t\tNever/Rarely/Sometimes | \n\t\t\t7 (50) | \n\t\t\t8 (53.3) | \n\t\t\t0.86 | \n\t\t\t15 (51.7) | \n\t\t
\n\t\t\t | Often / Always | \n\t\t\t7 (50) | \n\t\t\t7 (46.7) | \n\t\t\t\n\t\t\t | 14 (48.3) | \n\t\t
Continence data for interviewed patients.
Most patients (44/60, 73%) had soiling accidents at least once in the past year and this happened “often or always” in 22. 24 soiled only during the day and 20 soiled both during the day and overnight. There were none who soiled only at night. A higher proportion of females reported soiling episodes (female 19/21 vs male 25/39, p<0.05). 43 patients were able to quantify the usual size of soiling episodes that occurred during the daytime. This was medium to large in 26 (60%). Of the 18 who were able to describe the consistency of daytime soiling, 9 (50%) indicated that it was pasty. Eleven had episodes of daytime soiling but were usually unaware that these were occurring (more than 75% of the time). Nocturnal soiling was of pasty consistency in 60% (3/5) patients and medium to large amount in 43% (6/14).
Patients with a past history of high/intermediate malformations were more likely to “often or always” soil during the daytime than those with low malformations (soiling often/always: high/intermediate 15/28 vs low 7/31, p<0.05). Despite their revision, those with a PSARP still soiled more frequently (soiling often/always: PSARP 7/8 vs no PSARP 15/51, p<0.01). They were also more likely to soil at night (soiling often/always: PSARP 2/7 vs no PSARP 1/48, p<0.05).
Most patients could be classified as having either heavy or light soiling based upon frequency and amount of episodes. Nine patients (daytime soiling 1, nocturnal soiling 9) were unable to accurately define the amount or frequency of their soiling episodes. A third (12/33) of patients had “heavy” soiling. “Heavy” soiling was more likely to occur in patients with a high/intermediate malformation (“heavy”soiling: high/intermediate 10/16 vs low 2/17, p<0.01). It was also more common in males (“heavy” soiling: male 11/20 vs female 1/13, p<0.01) and patients who had undergone a PSARP (“heavy”soiling: PSARP 4/6, no PSARP 8/27, p<0.05).
Constipation (n=61) (Table 4)
We defined constipation as fewer than 3 stools per week or straining at stool for more than 25% of the time. Only 13% reported constipation occurring more than once a week. However, episodic constipation did occur. Twelve reported infrequent stools, 34 had hard stools and 39 had difficulty evacuating stools during the past year.
Patients with a low malformation were more likely to have had episodes of infrequent stooling during the past year (p<0.01).
\n\t\t\t | \n\t\t\t | High/Intermediaten (%) | \n\t\t\tLown (%) | \n\t\t\t\n\t\t\t\tp\n\t\t\t | \n\t\t\tTotaln (%) | \n\t\t
Constipation (n=61) | \n\t\t\tNever/Rarely/Sometimes | \n\t\t\t23 (85.2) | \n\t\t\t30(88.2) | \n\t\t\t\n\t\t\t | 53(86.9) | \n\t\t
\n\t\t\t | Often/Always | \n\t\t\t4 (14.8) | \n\t\t\t4(11.8) | \n\t\t\t1.00 | \n\t\t\t8(13.1) | \n\t\t
Infrequent stool (in past year) n (%) (n=60) | \n\t\t\tYes | \n\t\t\t1 (3.7) | \n\t\t\t11 (34.4) | \n\t\t\t0.00 | \n\t\t\t12 (20.3) | \n\t\t
If infrequent stools, number of episodes in last 3 months (n=9) | \n\t\t\t\n\t\t\t | 3.0 ± (-) | \n\t\t\t2.8±0.9 | \n\t\t\t0.91 | \n\t\t\t2.9±0.9 | \n\t\t
Hard stools (in past year) n (%)(n=60) | \n\t\t\tYes | \n\t\t\t15 (53.6) | \n\t\t\t19 (59.4) | \n\t\t\t0.58 | \n\t\t\t34 (56.7) | \n\t\t
If hard stools, number of episodes in last 3 months (n=26) | \n\t\t\t\n\t\t\t | 5.5 ± 6.5 | \n\t\t\t3.5 ± 3.3 | \n\t\t\t0.35 | \n\t\t\t4.5 ± 5.1 | \n\t\t
Difficulty in evacuating stool (in past year) | \n\t\t\tYes | \n\t\t\t20 (71.4) | \n\t\t\t19 (59.4) | \n\t\t\t0.33 | \n\t\t\t39 (65) | \n\t\t
n (%) (n=60) | \n\t\t\t\n\t\t\t | \n\t\t\t | \n\t\t\t | \n\t\t\t | \n\t\t |
If difficulty in evacuating stool, number of episodes in last 3 months (n=20) | \n\t\t\t\n\t\t\t | 7.0 ± 7.7 | \n\t\t\t5.4 ± 7.1 | \n\t\t\t0.63 | \n\t\t\t6.1 ± 7.2 | \n\t\t
Constipation data for interviewed patients.
Diarrhoea and rectal prolapse (n=57) (Table 5)
12% (7/57) of patients reported that episodes of diarrhoea occurred more than once a week. Patients with high/intermediate malformations were more likely to experience frequent episodes of diarrhoea.
Three patients (6% of 52) had constant anal excoriation and one had a rectal prolapse during the past year. Patients with a high/intermediate malformation were more likely to have perianal excoriation. Patients who had undergone a PSARP were also more likely to have perianal excoriation (excoriation: PSARP 3/8 vs no PSARP 6/44, p<0.05).
70% (42/60) of patients had episodic abdominal pain lasting more than two minutes. Of these, 10 reported abdominal pain 1 to 3 times per week and 9 reported pain 1 to 2 times per month. This was equally frequent in patients with a past history of either high/intermediate or low malformations.
\n\t\t\t | \n\t\t\t | High/Intermediaten (%) | \n\t\t\tLown (%) | \n\t\t\t\n\t\t\t\tp\n\t\t\t | \n\t\t\tTotaln (%) | \n\t\t
Diarrhoea (n=57) | \n\t\t\tNever/Rarely/Sometimes | \n\t\t\t20(76.9) | \n\t\t\t30(96.8) | \n\t\t\t\n\t\t\t | 50(87.7) | \n\t\t
\n\t\t\t | Often / Always | \n\t\t\t6(23.1) | \n\t\t\t1(3.2) | \n\t\t\t0.04 | \n\t\t\t7(12.3) | \n\t\t
Excoriation (n=52) | \n\t\t\tNever | \n\t\t\t17(68) | \n\t\t\t26(96.3) | \n\t\t\t\n\t\t\t | 43(82.7) | \n\t\t
\n\t\t\t | Sometimes | \n\t\t\t5(20) | \n\t\t\t1(3.7) | \n\t\t\t\n\t\t\t | 6(11.5) | \n\t\t
\n\t\t\t | Always | \n\t\t\t3(12) | \n\t\t\t0(-) | \n\t\t\t0.02 | \n\t\t\t3(5.8) | \n\t\t
Rectal prolapse (n=59) | \n\t\t\tYes | \n\t\t\t1(3.7) | \n\t\t\t0(-) | \n\t\t\t0.46 | \n\t\t\t1(1.7) | \n\t\t
Abdominal pain (n=60) | \n\t\t\tYes | \n\t\t\t21(75) | \n\t\t\t21(65.6) | \n\t\t\t0.43 | \n\t\t\t42(70) | \n\t\t
Abdominal pain (frequency) (n=32) | \n\t\t\t1-6 times in past yr | \n\t\t\t6(37.4) | \n\t\t\t7(43.8) | \n\t\t\t\n\t\t\t | 13(40.6) | \n\t\t
\n\t\t\t | 1-2 times in past month | \n\t\t\t5(31.3) | \n\t\t\t4(25) | \n\t\t\t\n\t\t\t | 9(28.1) | \n\t\t
\n\t\t\t | 1-3 times in past wk | \n\t\t\t5(31.3) | \n\t\t\t5(31.2) | \n\t\t\t1.00 | \n\t\t\t10(31.3) | \n\t\t
Diarrhoea data for interviewed patients.
Enuresis (n=56)
36% (20/56) of patients had enuresis at least once in the last 3 months. Nine had daytime enuresis, 8 had nocturnal enuresis and 3 had enuresis both during the day and at night. 16% of patients with daytime enuresis and 13% with night-time enuresis had an episode within the last week.
Patients with either daytime or nocturnal enuresis were younger than those who did not have enuresis (daytime enuresis 7.9 ± 5.0yr vs no enuresis 12.7 ± 6.3yr, p<0.05; nocturnal enuresis 9.0 ± 3.7yr vs no enuresis 13.1 ± 6.6yr, p<0.05).
Continence Aids (n=58)
29% (17/58) of patients used continence aids for soiling (6/17), enuresis (6/17) or both (5/17). Aids were used more frequently at night (12/58) than during the day (9/58). Daytime use was primarily for soiling, however nocturnal use was primarily for enuresis.
Patients with high/intermediate malformations were more likely to use aids at night (high/intermediate 8/26 vs low 4/32, p<0.05). Those who used aids overnight were younger than those who did not use them (continence aid use 7.7 ±3.6yr vs no use 12.7 ± 6.7yr, p<0.05).
Diet (n=61)
Over half (35/61) of patients reported adverse effects after some foods. Of these, 14 (40%) reported problems with fruit, 11 (31%) with vegetables, 16 (46%) with dairy, 12 (34%) with grains/breads/cereals, 13 (37%) with fatty or fast foods, 1 (3%) with meat, and 8 (23%) with other foods.
Overall, the most commonly reported adverse effects were diarrhoea (60%), constipation (28%) and abdominal discomfort (5%). Symptoms after fruit included diarrhoea (9/14, 64%), constipation (4/14, 29%) and peri-anal discomfort (2/14, 14%). Ingestion of vegetables was associated with diarrhoea (9/11, 82%) and constipation (1/11, 9%). Symptoms after dairy included diarrhoea (6/16, 38%), constipation (8/16, 50%) and abdominal discomfort (2/16, 13%). Grains/breads/cereals induced diarrhoea (7/12, 58%), constipation (3/12, 25%) and abdominal discomfort (1/12, 8%). Symptoms after fatty or fast foods included diarrhoea (7/13, 54%) and constipation (5/13, 38%). One patient experienced diarrhoea after meat.
54% (33/61) of patients either partially or totally restricted some foods from their diet because of these adverse effects. The most frequently restricted food groups were dairy (22%), fatty or fast foods (21%), fruit (17%) and vegetables (16%).
Medication (n=63)
Over half (34/62) of patients had used a medication or other treatment for bowel related problems in the past year. 29 patients used laxatives, 2 used anti-diarrhoeals and 10 used bowel washouts. Most (27/34) patients were using some form of treatment at the time of interview. Medication-users at the time of interview were significantly younger than those who did not use medication (current medication use 9.2 ± 4.7yr vs no medication 10.4 ± 5.3yr, p<0.05). Of those who were using medication, 12 were using more than one type of laxative. Those with a high/intermediate malformation were more likely to be using a medication (high/intermediate 20/28 vs low 14/34, p<0.05). Patients with soiling were also more likely to be using medication (soiling 27/44 vs no soiling 5/16, p<0.05). Those who used laxatives were significantly younger than those who used anti-diarrhoeals (mean age: laxative 8.9 ± 4.3yr vs anti-diarrhoeal 19.9 ± 2.4yr, p<0.05).
Physical and Social Aspects
6% (4/62) of patients had limited their physical activities because of soiling or odour.
Soiling interfered with social activities of 11 (19%) patients. Of these, 9 had some parental or self-imposed restrictions and 2 had extreme limitations. As expected, patients with soiling were more likely to have social limitations than patients without soiling (social limitation: soiling 11/40 vs no soiling 0/16, p<0.05). Odour from soiling was also responsible for interference with social activities in 14% (8/58) of patients. Of these, 5 patients were rarely affected and 3 were frequently affected.
When questioned on the level of dependency on toilet facilities, 3.5% (2/57) of patients had used toilet facilities at least once every 30 minutes, and 5% (3/57) had to use toilet facilities at least once every hour.
On average, patients had been absent from school 0.8 ± 2.4 days in the past two school terms.
Two of the 9 patients who were in part-time or full-time work reported some limitations to their employment because of bowel dysfunction.
Health Care (n=62)
58% (34/59) patients had not had a follow-up visit for their bowel in over a year. Of these, 15 had not had a follow-up visit in the past 5 years. Patients who had follow-up visits within the last year were younger (<1yr follow-up: young 0-11yr 20/39 vs old 12-33yr 5/20, p<0.001) and have a high/intermediate malformation (p<0.05). Patients with soiling were more likely to have had a follow-up visit in the past year (<1yr follow-up: soiling 19/41 vs no soiling 4/16, p<0.05).
12% (6/49) of patients who attended school had an integration aid for bowel related problems (ie. cleaning after soiling).
37% (23/62) of patients received financial assistance from the Commonwealth Government because of health issues (Health Care card). Patients with high/intermediate malformations (Health Care card: high/intermediate 15/28 vs low 8/34, p<0.05) and patients with soiling were more likely to have a health care card (Health Care card: soiling 21/44 vs no soiling 2/16, p<0.05) for bowel related problems.
27% (17/62) of patients received financial assistance in the form of a Disability allowance or their families received Carer’s allowances. Patients with soiling were more likely to have received Disability allowances (Disability allowance: soiling 16/54 vs no soiling 1/16, p<0.05) for bowel related problems.
Continence and Quality of Life Scores\n\t\t\t
Templeton continence scores could only be determined for 23% (14/62) of patients. Based on the Templeton classification, 3 patients had “poor”, 6 “fair” and 5 had “good” continence.
The requirement for digital anal examination meant that Holschneider classification of continence was able only used in 23% of patients. Four were classified as having “fair” continence, 7 “good” and 3 “normal”.
Classification of quality of life using the Ditesheim and Templeton scale was valid for 85% (53/62) of patients. Five patients had “fair” quality of life and 48 “good”.
Manometry (n=12) (Table 6)
Baseline anal sphincter pressures were significantly less than normal reference ranges, but there was little difference between those who did and did not soil. Recto-anal inhibitory reflexes were present in 5 patients, but the threshold volume for eliciting the reflex was significantly greater than normal. Sensation to rectal distension was also blunted. Most were unable to evacuate a water filled rectal balloon normally.
\n\t\t\t | SoilingNever//Sometimes | \n\t\t\tSoilingOften/Always | \n\t\t\t\n\t\t\t\tp\n\t\t\t | \n\t\t\t\n\t\t\t\tTotal\n\t\t\t | \n\t\t\t\n\t\t\t\tHistorical normal values\n\t\t\t | \n\t\t\t\n\t\t\t\tp\n\t\t\t | \n\t\t
Baseline sphincter pressure (mean±SD) | \n\t\t\t38.1±20.8 | \n\t\t\t37.9±20.8 | \n\t\t\t0.99 | \n\t\t\t38±19.4 | \n\t\t\t53±12 | \n\t\t\t<0.01 | \n\t\t
Recto-anal inhibitory reflex | \n\t\t\t\n\t\t\t | \n\t\t\t | \n\t\t\t | \n\t\t\t | \n\t\t\t | \n\t\t |
• Normal | \n\t\t\t1 | \n\t\t\t1 | \n\t\t\t\n\t\t\t | 2 | \n\t\t\t\n\t\t\t | \n\t\t |
• Present but abnormal | \n\t\t\t1 | \n\t\t\t2 | \n\t\t\t\n\t\t\t | 3 | \n\t\t\t\n\t\t\t | \n\t\t |
• Not present | \n\t\t\t1 | \n\t\t\t4 | \n\t\t\t0.64 | \n\t\t\t5 | \n\t\t\t\n\t\t\t | \n\t\t |
Recto-anal inhibitory reflex (if present) – threshold (mL) | \n\t\t\t35±7.1 | \n\t\t\t32.5±15 | \n\t\t\t0.84 | \n\t\t\t33.3±12.1 | \n\t\t\t16±7 | \n\t\t\t<0.01 | \n\t\t
Sensation to distension (mL) | \n\t\t\t69±79.9 | \n\t\t\t90±65.4 | \n\t\t\t0.62 | \n\t\t\t80.5±69.4 | \n\t\t\t14±7 | \n\t\t\t<0.01 | \n\t\t
Co-ordination | \n\t\t\t\n\t\t\t | \n\t\t\t | \n\t\t\t | \n\t\t\t | \n\t\t\t | \n\t\t |
• Relaxation | \n\t\t\t2 | \n\t\t\t1 | \n\t\t\t\n\t\t\t | 3 | \n\t\t\t\n\t\t\t | \n\t\t |
• No change | \n\t\t\t2 | \n\t\t\t2 | \n\t\t\t\n\t\t\t | 4 | \n\t\t\t\n\t\t\t | \n\t\t |
• Anismus | \n\t\t\t0 | \n\t\t\t2 | \n\t\t\t0.33 | \n\t\t\t2 | \n\t\t\t10% | \n\t\t\t\n\t\t |
Ability to evacuate water-filled balloon | \n\t\t\t\n\t\t\t | \n\t\t\t | \n\t\t\t | \n\t\t\t | \n\t\t\t | \n\t\t |
100mL | \n\t\t\t1 | \n\t\t\t1 | \n\t\t\t\n\t\t\t | 2 | \n\t\t\t100% | \n\t\t\t\n\t\t |
50mL | \n\t\t\t1 | \n\t\t\t2 | \n\t\t\t\n\t\t\t | 3 | \n\t\t\t\n\t\t\t | \n\t\t |
30mL | \n\t\t\t0 | \n\t\t\t0 | \n\t\t\t\n\t\t\t | 0 | \n\t\t\t\n\t\t\t | \n\t\t |
Unable | \n\t\t\t2 | \n\t\t\t4 | \n\t\t\t\n\t\t\t | 6 | \n\t\t\t\n\t\t\t | \n\t\t |
Manometry results from 12 patients.
Down’s Syndrome Group (n=3)
The three patients with Down’s syndrome and high/intermediate anorectal malformations were 12 ± 3.4 years old. Two were male and one female. Two had a redo PSARP operation. Co-morbidities included cardiac, gastrointestinal (non colorectal), renal and respiratory.
All three had a bowel action each day. Stool consistency was formed in two and pasty in one patient. Two patients could hold back stool more than 75% of the time.
All three had soiled within the past year. Three “often” had daytime soiling episodes. Daytime soiling varied between a pasty to formed consistency and streak to large amount. One “often” soiled nocturnally and two wore nappies at night.
Only one patient had constipation and abdominal pain. The other two had episodic diarrhoea, and one also had anal excoriation.
One patient had both day and night enuresis and one only had daytime enuresis in the last week.
One patient used incontinence aids day and night for enuresis and soiling and another also used incontinence aids for enuresis and soiling but only at night.
No patient had any limitations to their physical activities but one did limit social activities because of odour from soiling, and one needed access to toilet facilities every 30 minutes.
All patients had a health care card and received disability allowance.
Only two patients had a follow-up for their bowel in the past 12 months. One was using laxatives at the time of interview for bowel control and another patient had used laxatives in the past year but had ceased 4 months prior.
All three had adverse effects from foods. These foods included fruit, vegetables and fatty or fast foods. The effects from these foods included diarrhoea and abdominal discomfort.
Social impact of incontinence – parental free comments (overall group of 62)
Earlier diagnosis:
One parent felt as though diagnosis (of ARM) could have been made sooner if they (parents) had been more assertive. It took a day to diagnose although the Mother knew that something was not right with her son after birth, despite the nurses saying that he was fine.
Genetics:
Two mothers thought there might be a genetic link. One mother was concerned about her future pregnancies. Two mothers were also concerned about the chance of their children’s children having malformations.
Social limitations:
One patient was teased at school because she wore a nappy and this would really upset her. Two patients were limited in their social activities because they were embarrassed to sleep over at friends or did not go to camps because of inadequate toilet facilities. School was difficult for one boy because he had to go to the toilet quite frequently during class.
Coping:
Parents and patients coped with the disease in various ways. Three parents said that you just have to deal with it, with one adding that that was her role as a mother. One family put the disease into perspective for their child by saying that it could be a lot worse. One parent felt that being open and not making a big deal would hopefully decrease the chance of problems in the future. One mother said that you “have to have a sense of humour or you just go nuts”.
One parent said that she had to block out how bad the anal dilatations were in order for her to perform them. Two patients said that they had learnt to deal with it, with one stating that there was no need to dwell on it and another saying that you would cope with whatever happened when it came. One mother said that at times her daughter was quite upset with her malformations and procedures, however she understands their need. One patient felt that there is nothing he can do so he just deals with it. One patient always asks his parents why it has happened to him. One patient used to ask why this happened to her and feel really helpless.
One parent said that the disease affects the whole family, not just the patient. Three parents were quite distressed about having to give their children treatment (medication, bowel washouts or anal dilatations). One parent said that it was upsetting to see their child go through it all. One mother said that it was “mentally destroying” to hear her baby crying all the time when he was passing bowel actions. She said that she did not know how she coped without any help. One patient developed a fear of going to the toilet because he would be in so much pain.
Associated disabilities:
There were some questions by both parents and patients surrounding physical ability and if this was the reason for soiling.
Medical interactions:
A few parents wanted more follow-up visits to occur and at more frequent times so they could monitor their child’s progress. One parent did not feel that there was a need to see her doctor because he did not offer her any new information.
This review reaffirms the importance of problems with bowel control in the long term outcome after surgical repair of anorectal malformation. Over two thirds of patients had faecal incontinence over the past year and half of these had soiling which occurred either often or always. Half of all the patients soiled both during the day and at night. As expected, patients with high/intermediate malformations were more severely affected. The most severe “heavy” soiling occurred in approximately a fifth of the patients. These patients were more likely to be male or have high/intermediate malformations.
There was evidence that bowel control improved with age, but faecal urgency was still a problem in half of those aged 12 years and over. Children with low malformations tended to be less severely affected but there was also a suggestion of a slightly different symptom complex. Constipation was more common in patients with low malformation and diarrhoea more common in patients with high/intermediate malformations. Those with Down syndrome also had a poor outcome but we had no direct comparison group for this small number of children.
Only one quarter of potentially eligible patients in our study were surveyed. It is possible that this may have skewed the results toward a poorer outcome. Certainly, some studies do show rather better outcomes, with only 20% having faecal incontinence using some scoring systems [17]. However, other studies have shown broadly similar long term outcomes for continence and quality of life [18-21].
The long term functional impact in adults upon continence and quality of life can be devastating. Rintala et al. examined the outcome for adults (mean age 35 years) in terms of quality of life following surgical repair high or intermediate anomalies compared to low anomalies [22, 23]. This pair of controlled studies determined that good continence was present in only 18% of patients with high or intermediate anomalies and in 60% of those with low anomalies. Pelvic dysfunction extended into other areas. Sexual dysfunction was present in 30% of those with high or intermediate anomalies and 13% of those with low anomalies.
Further operations have been offered and there is some evidence supporting a role for posterior sagittal anorectoplasty (PSARP) with or without provision of an antegrade continent enema in selected patients with persistent and unresponsive soiling [24]. However, in our study, soiling persisted even in those patients who had received a PSARP, suggesting that it may improve function it does not usually return bowel function to normal.
Other therapies have been offered. Biofeedback has been suggested in uncontrolled studies to provide substantial improvement in continence after surgical repair of ARM [25-28]. This should be evaluated critically as biofeedback has shown similar promise in uncontrolled studies of childhood encopresis which disappeared when evaluated within the framework of fully case-controlled trials [29].
Enuresis was also a problem in many patients. Some of these children may have also had urinary system anomalies. Where they occur, it has been suggested that they are at least as serious and complex as gastrointestinal anomalies, and contribute substantially to long term morbidity [17].
The social impacts of chronic gastrointestinal and urinary dysfunction are substantial. Approximately a quarter of the respondents in our study were on some form of financial health care assistance. Some of the comments made by parents would seem to go against the relatively optimistic outcomes on quality of life as determined by the Ditesheim and Templeton scale in our study, which suggested over three-quarters had a “good” quality of life. Quality of life measures can be extremely difficult to establish and there may be a case for looking more carefully at developing more specific and sensitive parameters [10].
An interesting observation was the impact of diet on bowel dysfunction. There is relatively little information on this area in the literature although an earlier study by the same authors in children with Hirschsprung disease identified similar findings in that group [14]. Many of the food groups which were problematic included either fibre-containing products (vegetables), lactose (dairy) or grains. There has certainly been a great deal of recent interest in the impact of rapidly fermentable, short-chain carbohydrates on functional bowel disease [30]. These have been given the acronym “FODMAPS”, and found to have a substantial impact on functional abdominal pain, bloating and diarrhoea which are symptoms of irritable bowel syndrome [30]. Why this should be a particular problem in children after anorectal surgery such as Hirschsprung or anorectal malformation is not clear but may relate to the loss of a “rectal brake”.
The assessment of residual function can be difficult. Several clinical-based protocols have been developed, but are poorly standardized with poor inter-scale correlation [31]. Anorectal manometry can identify a range of dysfunctional parameters which might be thought likely to contribute to incontinence [32]. In our study, a number of indices were markedly abnormal. Sphincter pressures were low. Sensory thresholds to rectal distension were extremely blunted. The rectoanal inhibitory reflex was often impaired, or only elicited with very high rectal distending volumes. Incoordinate defaecation was common, as was inability to evacuate a water filled balloon. What is interesting is that there was very little statistical difference between those who soiled heavily and those who had little soiling in terms of anorectal manometric parameters. It is likely that other pathophysiological “triggers” tip the balance in favour of heavy soiling.
Rapid colonic transit may be one such trigger. Ingestion of rapidly fermentable, short-chain carbohydrates is quite likely to lead to more rapid movement of luminal content with the potential for overcoming rectal control. There are varying abilities to tolerate fermentable loads, and these depend (amongst other factors) on rate of ingestion, concomitant nutrients, small intestinal processing, and colonic flora together with their metabolic activities. There is substantially more diversity in colonic flora than previously thought, with close interactions between environment, host genotype and the metabolic functioning gut microbiome [33]. If gut microbiome does play a role in faecal incontinence in this group, however minor, it represents an opportunity for therapeutic intervention.
The twenty-first-century higher education landscape in the world in general and in South Africa in particular is a very complex one, plagued by a variety of challenges and opportunities. The level of preparedness by both students and the university determines the kind of educational encounters students will have and how such encounters will shape their educational journeys. Students’ preparedness for higher education is seen as one of the main factors affecting first-year attrition or study success. Cloete [1] argues that “from assessments of the South African system by the Harvard panel on Accelerated and Shared Growth Initiative –South Africa, the World Bank and the Centre for Higher Education Trust, South African higher education system could be characterised as low participation with high attrition rates, with insufficient capacity for adequate skills production” (p. 3). This points to the challenges the South African higher education landscape is facing and how these have persisted for over 20 years after the end of apartheid. Fomunyam [2] concurs with this by arguing that about 40 percent of students who enter higher education institutions in South Africa end up dropping out and only about 15 percent complete their degree in the minimum completion time. Though the reasons for this vary from context to context, Lemmens [3] argues that the major reason can be attributed to the level of student and institutional preparedness. How prepared both the student and the institution are for the educational encounter is likely to determine the level of student performance in the classroom and the ultimate completion of the programmes.
Monnapula-Mapesela [4] argues that in South Africa, student under-preparedness has become a dominant learning-related cause of the poor performance patterns in higher education. He further states that “surprisingly and of concern, is the fact that still no single university in South Africa, inclusive of those that admit only the cream of the crop, can safely deny students’ unpreparedness, high dropout rates, poor throughput, low success rates despite innumerable academic support structures in place, as amongst some of the challenges that confront the country’s higher education” ([4], p. 256). Student under-preparedness is therefore a widely recognised issue in South African higher education though the reasons for under-preparedness vary from student to student. The contextual nature of student preparedness in South Africa can be understood as influenced to a greater extent by the political history of the country so that its subtle effects are still being felt within all sectors of education. The fact also remains that the level of social, political and economic capital possessed by different students, which in itself is the result of the socio-economic status of their families, has actually played a major role in the kind of learners being produced and ultimately applying to universities.
Institutional preparedness, as stated above, must also be considered. Manik [5], Cloete [1] and Fomunyam [2] argue that most South African institutions are still grappling with transformation, making them strategically underprepared for the quality of students being ushered into the higher education system. Most universities in South Africa by and large are still being influenced by the culture inherited from apartheid; they fail to attract and retain the best academics and researchers who find more remunerative work elsewhere. Within higher education there is the enormous differentiation between institutions—the abiding differences between historically white universities and historically black universities, and the under-resourced nature of some of these universities makes it increasingly difficult for underprepared students to succeed. Therefore, South African higher education appears caught between the disabling legacies of the past and the structural pressures of the present. The danger is that these twin forces become excuses for inaction—to throw up one’s hands and point fingers at apartheid or neoliberalism.
Students’ access, preparedness and success are widely debated issues in South African higher education institutions, student under-preparedness being articulated as the dominant learning-related cause of the poor performance patterns in higher education, largely blamed on systemic faults of the school sector (Du [6]). This level of under-preparedness magnified the widening of access to the larger population, particularly to non-first-language English-speaking students. This is often done with the expectation that universities will intensify support for students in a number of ways, including financial, accommodation, food, health, academic and career advising, life and academic skills and literacies, counselling and performance monitoring, and through referrals to various support programmes [7]. The under-preparedness of the university goes a long way to magnify the under-preparedness of students, thereby creating the perfect ground for poor educational encounters and tensions within the classroom.
The Council on Higher Education [7] stated that for many South African universities, the dawn of democracy resulted in policy-driven higher numbers of previously disadvantaged students in university studies. In spite of this apparent improvement, enough was not done to ensure the continuous access and subsequent success of these students. Universities are expected to set measures in place which would address the imbalances of the past and ensure that those with limited social, political, economic and cultural capital are empowered enough to co-construct knowledge effectively within the higher education landscape. Roman and Dison [8] arguing in this light point out that universities need to address the “general lack of academic preparedness, multilingual needs in English-medium settings, large class sizes and inadequate curriculum design” (p. 30). The challenge for higher education institutions is not only dealing with the level of preparedness and increasing the diversity of the student population but also involves the provision of quality education. The Council on Higher Education [9] confirms the under-preparedness of universities in South Africa to deal with structural challenges affecting students when it argued that “student experiences posits that the existing cohort of students is not necessarily underprepared, and that failure to succeed lies more in systemic weaknesses in higher education” (p. 10). Therefore, there is a need for universities to fully understand students’ thinking to deliver educational practices that will allow them to achieve their full potential while bearing in mind that learning takes place on the basis of social activity.
The Department of Higher Education and Training [10] posits that universities in South Africa are supposed to provide citizens with high-level skills for the labour market, be centres of research excellence, since they are (or are supposed to be) the dominant producers of new knowledge, or find new applications for existing knowledge in order to keep South Africa independent, inventive and able to stave off intellectual subordination to developed, post-industrial countries. The white paper concludes that universities are also supposed to be responsible for social justice and for creating equity and the equitable conditions to reverse the damaging effects of apartheid. The inability of most universities in South Africa as pointed out by Chetty and Pather [11] has resulted in poor throughput rates because institutions are not adequately prepared for its mission or purpose. Student and institutional preparedness must therefore be understood as key drivers of throughput and educational encounters.
Educational encounters within the classroom powered by both student and institutional preparedness determine how students perform in the university. The first-year experience is critical in influencing high dropout rates and low throughput rates. To tackle this challenge, institutions must address and enhance their academic capabilities as universities, and specifically academics, and rigorously conceptualise and design high-quality academic development programmes to support academics and students. However, to understand this complex challenge of student and institutional preparedness, it is critical to look at marginalised students who possess what is needed to succeed within the institution. By exploring their views and those of the academics teaching them, a concrete understanding is what is needed regarding the level of preparedness by both the students and the institution and what can be done to enhance such preparedness to ensure better educational encounters in the classroom. This description of the current situation in South Africa provides the background for this study.
This research was designed and conducted as a qualitative case study. Fomunyam [12] defines qualitative research as research which seeks not only depth but also the complexity of the phenomenon in an attempt to unearth both the particularities and peculiarities (“the what” and “the how”) of the phenomenon so as to enhance understanding or develop a theory. In this case, qualitative research sought to explore student and institutional preparedness for educational engagements and encounters. Since the focus of the research was seeking or exploring student and institutional preparedness, the case study approached was engaged. Elman, Gerring and Mahoney [13] argue that case study research explores complex problems whose core is difficult to find or whose root cause is difficult to explain. Explaining such a complex problem, therefore, would require focus on that particular issue and investigation using several instruments or exploring it from different angles. The case study approach offered the opportunity of studying student and institutional preparedness for educational encounters. The case here is the university and the unit of exploration is students and staff. The university under study is a university of technology in the province of KwaZulu-Natal. The high student dropout and low-throughput rates within the university are a direct result of student and institutional preparedness. Most of the students within the university possibly failed to gain admission into other universities before settling for the University of Technology. To generate data from these participants, two approaches were used: the open-ended questionnaire and the interview. The open-ended questionnaire was administered to students, and the interview was done with lecturers. The open-ended questionnaire was administered after 5 weeks of lectures, while the interview was done at the end of the semester creating a space of about 7 weeks in between the interviews. The open-ended questionnaires were administered to students to explore their level of preparedness. Fomunyam [14] argues that open-ended questionnaires consist of open-ended questions delivered to respondents with the aim of generating a particular kind of information. The open-ended questionnaire gives the participants the opportunity of expressing themselves and providing all the details they think are important. The questions are not limiting in any way. The open-ended questionnaire was administered to first-year students. About 624 first year students from 3 faculties completed the questionnaire. The lecturer’s interviews were conducted with the six lecturers (two each from the three faculties) teaching the first-year students. Each interview lasted for 1 hour with the researcher using tape recorders to capture the interview. The researcher obtained permission from the university to conduct the research, and every participant (both the students and the lecturers) understood their participation was voluntary and they could withdraw at any time. The lecturers signed a consent form before the interview was conducted, while the students understood that by completing the questionnaire, they were by default giving consent; those who were uncomfortable participating simply had to refuse filling the questionnaire or fail to return it. The data generated from these two sources were coded and categorised into themes. These themes speak to students and institutional preparedness for educational encounters.
The data generated from both the interviews and the open-ended questionnaires were coded and categorised into themes. Two themes, social and cultural capitals and cognitive skills, emerged with regard to student preparedness, while another two themes emerged with regard to institutional preparedness, educational architecture and institutional culture.
The level of social and cultural capitals a student possesses determines how ready he or she is for educational encounters in the classroom. Since educational encounters are built on the basis of this capital, the more a student possesses, the more prepared or ready the student is for educational encounters. One of the participants pointed out that “most of the students lack the experiences and know-how needed to co-construct knowledge in the classroom. This makes teaching and learning extremely difficult because the teaching has to be the all-knowing in the classroom while students become passive recipients waiting to be filled”. Another participant added that “this place is not easy. I was lost the first time I came here I felt like going back home. I was so lost. Cause imagine from primary to high school I have never been in a class with someone who is not Xhosa. And when especially I was interested in other races, whites and, you see I was so I was completely lost. I didn’t know what to do, like I just watched them take my bags and I was like yoh I’m not going to cope in this institution. I’ve never seen it like this, many white and Indian people in my entire life [laughing]. So it was a difficult experience for me. And again had to communicate in English, of which I wasn’t used at all speaking English”. The feeling of awe in the student puts him in a compromising position in the classroom. Students can barely find their way around understanding the dynamics of the institution and talk less of coming to terms with the racial diversity of the nation amongst other things. These begin to hamper the educational encounters students have in the classroom. The idea of under-preparedness was further supported by another participant who pointed out that “In high school, my teachers would explain some of the things in school when we don’t understand what they are saying in English. But here we are taught using English. At times I don’t understand half of the things the lecturer is saying. I have to go back and ask my friends. It is too much”. Another participant further added that “You know; it’s very hard to understand some of this Indian or white people when they speak. And then you speak and don’t know some of the words in English. You just stop there of say it in Zulu and they don’t understand what you are saying. This has really affected my studies (sighs). I failed four of my test”. The lack of social and cultural capitals amongst the students determines the kind of educational encounters they have in the classroom. The lack of capital inhibits their development of commensurate agency which is needed for critical engagement in higher education. The level of student preparedness for educational encounters is a direct function of the capital he or she possesses, and the encounters in turn determine the kind of performance they produce and whether or not they eventually graduate.
Skills are vital for every educational endeavour, and it becomes particularly critical in the higher education arena where students are expected to perform a variety of tasks using several cognitive skills. To succeed in the higher education landscape especially for students with low levels of social and cultural capitals, there is a need for a variety of skills like note taking, writing, critical thinking, adaptability, creativity, listening, time management, networking, leadership, presentation and resilience, amongst others. Speaking about the importance of this, one of the participants pointed out that “Some of this students don’t even know how to listen in class or take notes. They are distracted for more than half of the class. Some show of very late and hardly ever understand the lesson. At the end when they fail an assignment and you ask them to redo it, some of them just give up or simply want to give up. This makes the chances of their success very slim”. Another participant added that “the lectures are too tiring and some of the lecturers just leave you to do all the work. Managing everything is very difficult. I don’t have any friends, and I am yet to understand life in this city which very different from where I come from. People here don’t care. At times I wake up when the bus for school has left already and I have to wait for the next one which is in two hours maybe and misses my classes. I need help”. The lack of basic cognitive skills with which to navigate through teaching and learning determines the kind of educational encounters students have in the classroom. Some students lack the skills necessary to make constructive engagements not only with the content being discussed in the class but also outside the classroom. Speaking on this one of the participants pointed out that “the teachers are so fast in ways that I can’t hear most of what they are saying. At times I would get notes from my friends and at times they would refused to give or tell me they didn’t write. Lecturers want us to do presentations, use computers and power points and stuff. I am still trying to learn those things”. A variety of cognitive skills are needed to successfully navigate the higher education landscape. The lack of vital cognitive skills is amongst the reasons for poor educational encounters which make for success in academics.
The data also revealed that not only are students ill-prepared for educational encounters, but the institution is ill-prepared as well. The data reveal that the university was littered with poor educational architecture which did little to ensure that students got the best educational experience. Such educational architecture informed the kind of educational encounters students had in the class. One of the participants pointed out that “as a lecturer you have about 120 students in a class which is probably supposed to conducively accommodate 80. It is impossible to engage such a large number of students for a lecture spanning 90 minutes. At the end, the lecturer and one of two students become participants in the knowledge construction process while the others remain passive listeners”. Another participant added that “institutional structures are very unfriendly. They just expect you to know everything. They forget you doing this for the first time. You stand in queue for more than two hours just to get a form signed or to pick a group or submit an assignment and stuff. it’s very annoying”. The educational architecture within the universities determines the kind of experiences students have in the class and the kind of engagements and encounters that ensue. Another participant added that “the classes are not properly ventilated. We almost suffocate in class when it’s hot because we are always more than the class can contain and some students are always seating on the floor”. Another participant yet added that “the classes and overcrowded and yet there are no microphones in the classroom. The lecturer has to shout and some students are always fidgeting because they trying to ask their friends what is being said. These distractions impact the kind of educational encounters happening in the classroom”. If students cannot hear or participate in the knowledge construction process happening in the classroom, then they cannot own the knowledge constructed, meaning no meaningful learning actually takes place. Another participant further added that “the university lack basic educational or teaching and learning facilities like projectors in the classrooms, white boards or responsive boards, enough computers in student’s LANs, enough lecturers and administrative staff to handle the student population. For example, some posts have been vacant in this institution for a year, some two years and some even three, all of which are vital positions requiring key personal to hold them”. The educational architecture of the institution points to the level of preparedness by the institution for educational encounters in the classroom. Poor planning or preparation leads to poor encounters which hamper throughput rates and cause wanton failure and increases dropout rates.
Institutional culture influences everything happening in and around the university campus from the way lecturers teach to the way students are welcomed and treated and the way they are made to feel within the university. Institutional culture is at the epicentre of higher education and would directly and indirectly influence the educational encounters students have in the classroom as well as determine whether or not the university is ready to receive the diverse student body, which represents the diversity within the nation. Speaking about the culture of the institution and the role it plays in the education of the students, one of the participants pointed out that “the university has a culture of throwing the students into the proverbial deep end to either swim or sink. This is done in a variety of ways, from hiring mentors who themselves lack enough social capital to assist their peers in their educational endeavours, to providing support which addresses the kind of help the university think students need rather than provided targeted support to students when they need them”. Another participant pointed out that “there is general culture of resistance to change around the university. The old staff who have been there for years won’t give the new and younger staff members the opportunity to innovate. They lord it over them and stifle them to stay within the culture of under-productiveness and conformity to the statuesque”. Though institutional culture cannot be seen, it is experienced all over the university campus. Universities of technology all over South Africa have the culture of focusing more on technical know-how and pattern development rather than research focused on better ways of teaching and learning. This makes teaching and learning unresponsive to the new demands in teaching and learning and the diversity evident in the classroom. Confirming this, one of the participants pointed out that “the way some lecturers were teaching five or ten years ago, is still the same way they are teaching now. There is no difference in their philosophy and the pedagogy. They see all students as the same”. Another added that “universities of technologies are often seen as the place for the not so bright who have been rejected by other mainstream universities. As such the problem is the quality of student and no matter what you do, most of them will still fail and drop out. This cultural and capital deficiency approach to viewing students already creates a block in the teaching and learning process because the lecturer can never give their best”. Institutional culture therefore presents a significant challenge to the educational encounters happening within the university and by and large shapes the direction of such encounters and how students experience such encounters.
From the findings it is clear that social and cultural capitals, cognitive skills, educational architecture and institutional culture are important factors influencing student and institutional preparedness for educational encounters. Harker, Mahar and Wilkes [15] argue that when students shift or switch from one social field to another (leaving home or local community to the university as is the case with most of the students), they may experience difficulties transferring capitals between fields. This was the case for some of the participants of this study as they strived to develop more capital to tap into in the knowledge construction process. Since capital is the basis of knowledge construction, their ability to construct knowledge is hampered by their inability to develop or possess the right kind of capital. Tzanakis [16] argues that cultural capital is especially transferred by family and education, be it formal or informal, and may be institutionalised or engaged with nominally like group meetings, mentoring programmes, extended programmes and foundation programmes, amongst others. Capital is the primary cause for educational encounters and relative positions within the educational larder. Levina and Arriaga [17] add that cultural capital can exist or be incorporated in three forms, the embodied, the objectified and the institutionalised states, of which the objectified and the institutionalised indicate the possession of cultural artefacts and educational credentials. The embodied state is critical to an individual because it involves an ability to decipher the “cultural codes” which are composed of material cultural objects, for example, writings, paintings and monuments. Preparedness for educational encountered for both the student and the institution is hampered by capital. The kind of capital required for the students to construct knowledge is missing, and the cultural codes around the university which makes for its culture and architecture also present a challenge in itself for students and the drive for better educational encounters in the classroom.
Bourdieu [18] expounds on the interconnectedness of culture, architecture and capital in the educational experience by arguing that learning is sponsored by “systems of durable, transposable dispositions, structured structures predisposed to function as structuring structures, that is as principles of generation and structuring of practices and representations which can be objectively ‘regulated’ and ‘regular’ without in any way being the product of obedience to rules, objectively adapted to their goals without presupposing a conscious aiming at ends or an express mastery of the operations necessary to attain them and, being all this, collectively orchestrated without being the product of the orchestrating action of a conductor”(p. 72). This means that there are a variety of forces at play influencing educational encounters and institutions and the powers that must take action and responsibility to ensure that these forces are dealt with. The multifaceted nature of the forces at play determine preparedness and how successful or unsuccessful educational encounters are for the students attending the university. The more capital and cognitive skills the student possesses, the more they are predisposed to succeed. Within the context of the findings, it is clear that both the educational architecture and institutional culture of the higher education institutions in South Africa are ill-prepared for educational encounters with students. The right kind of architecture and culture would improve the quality of educational encounters and make for better student performance.
Manik [5] argues that both students and universities are often underprepared for higher education, and universities often need to do more to assist underprepared students as well as transform themselves to become better-prepared institutions so as to foster better educational encounters. Lewin and Mayoyo [19] add to this by arguing there are several factors influencing access and success at university, and these are complex and multidimensional. To them, student preparedness is influenced by schooling background, socio-economic status, race and gender and the social context of learning, student and staff ratio, pedagogy, language and literacy. With the participants articulating these as issues influencing or affecting their educational experience, institutions need to take these factors into consideration if throughput rates must increase, and the educational architecture and the institutional culture must be revisited to pave way for new and better facilities which would ensure that the right kind of educational encounters are garnered. Heymann and Carolissen [20] confirm this when they argue that students must be understood as having “real challenges” and in need of institutional support, but they caution that a patronising attitude should be avoided in classifying students according to categories which will lead to labelling: being “pathologised as problematic” for their specific needs. Sosibo and Katiya [21] further buttress this when they argue that institutions need to provide specialised support especially the acquisition of skills and recognise that students may be struggling with critical skills in English such as speaking, reading and writing. This means that universities need to support students to develop cognitive skills as a way of giving them a wide variety of tools with which to navigate their way in the higher education sector. They continue that “under-preparedness refers to the state of students who are in general not academically ready, especially in areas such as reading and writing, and particularly in the language of learning and teaching, which in most cases is English” (p. 274). And this under-preparedness of both students and the university can be improved by considering two key factors which Prinsloo [22] names as timing and appropriateness. In order to be able to provide timeliness and appropriate academic support, institutions need to be able to identify students who need such support at an early stage so as to track and monitor their progress and to evaluate the effectiveness of support systems and programmes offered.
Student and institutional preparedness for educational encounters is a product of a variety of issues. How these issues are addressed will determine whether or not a student’s educational experience improves. From the findings, it is clear that social and cultural capitals, cognitive skills, educational architecture and institutional culture are amongst some of the drivers of educational encounters for students in the classroom. The effects of such encounters are heavily dependent on the levels of preparedness and the drivers that determine such a level. Institutions must therefore recognise the fact that not only are students underprepared but universities themselves are becoming increasingly underprepared as access increases and throughput rates are low. With this in mind, this chapter makes four key recommendations for better educational encounters in the classroom. Firstly, universities need to recognise their capacity and work to improve such capacity in the wake of massification as a way of improving throughput rates especially because they would continuously attract students of similar background or with similar challenges. Secondly, educational encounters are a direct product of work between both the university and students, and specialised support should be tailored and provided to students who need them as a way of empowering them for an improved educational experience. Thirdly, students must strive to improve themselves and garner more capital as they navigate their way through the higher education landscape, for capital is the very currency of educational encounters, and such encounters determine whether or not students succeed and when students succeed. Finally, higher-education stakeholders need to theorise more deeply the ability of higher education institutions to accommodate a certain number of students as well as the ability of certain students to navigate their way through the higher education landscape as a mechanism to ensure that both the institution and the students coming to such institutions are ready for educational encounters in the classroom. This kind of educational encounters is more likely to produce meaningful transformation in both the student and the institution as well as improve throughput rates and guarantee public returns for South Africa’s investment in higher education.
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\n\nPolicy last updated: 2018-09-11
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